Caesarean birth as a component of surgical services in low- and middle-income countries

As global attention to improve the quality, safety and access to surgical care in low- and middle-income countries (LMICs) increases, the need for evidence-based strategies to reliably scale-up the quality and quantity of surgical services becomes ever more pertinent. Iversen et al discuss the optimal distribution of surgical services, whether through decentralization or regionalization, and propose a strategy that utilizes the dimensions of acuity, complexity and prevalence of surgical conditions to inform national priorities. Proposed expansion of this strategy to encompass levels of scale-up prioritization is discussed in this commentary. The decentralization of emergency obstetric services in LMICs shows promising results and should be further explored. The dearth of evidence of regionalization in LMICs, on the other hand, limits extrapolation of lessons learned. Nevertheless, principles from the successful regionalization of certain services such as trauma care in high-income countries (HICs) can be adapted to LMIC settings and can provide the backbone for innovation in service delivery and safety.

Download Full-text

Caesarean birth by maternal request: a poorly understood phenomenon in low- and middle-income countries

International Health ◽

10.1093/inthealth/ihaa020 ◽

2020 ◽

Author(s):

Margo S Harrison ◽

Ana Garces ◽

Lester Figueroa ◽

Fabian Esamai ◽

Sherri Bucher ◽

...

Keyword(s):

Logistic Regression ◽

Mixed Effects ◽

Multiple Gestation ◽

Hypertensive Disease ◽

Maternal Request ◽

Middle Income ◽

Middle Income Countries ◽

Caesarean Birth ◽

Medical Indications ◽

Low And Middle Income

Abstract Background While trends in caesarean birth by maternal request in low- and middle-income countries are unclear, age, education, multiple gestation and hypertensive disease appear associated with the indication when compared with caesarean birth performed for medical indications. Methods We performed a secondary analysis of a prospectively collected population-based study of home and facility births using descriptive statistics, bivariate comparisons and multilevel mixed-effects logistic regression. Results Of 28 751 patients who underwent caesarean birth and had a documented primary indication for the surgery, 655 (2%) were attributed to caesarean birth by maternal request. The remaining 98% were attributed to maternal and foetal indications and prior caesarean birth. In a multilevel mixed effects logistic regression adjusted for site and cluster of birth, when compared with caesareans performed for medical indications, caesarean birth performed for maternal request had a higher odds of being performed among women ≥35 y of age, with a university or higher level of education, with multiple gestations and with pregnancies complicated by hypertension (P < 0.01). Caesarean birth by maternal request was associated with a two-times increased odds of breastfeeding within 1 h of delivery, but no adverse outcomes (when compared with women who underwent caesarean birth for medical indications; P < 0.01). Conclusion Caesarean performed by maternal request is more common in older and more educated women and those with multifoetal gestation or hypertensive disease. It is also associated with higher rates of breastfeeding within 1 h of delivery.

Download Full-text

Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries

Cochrane Database of Systematic Reviews ◽

10.1002/14651858.cd011307.pub2 ◽

2017 ◽

Cited By ~ 1

Author(s):

Jacqueline Ramke ◽

Jennifer Petkovic ◽

Vivian Welch ◽

Ilse Blignault ◽

Clare Gilbert ◽

...

Keyword(s):

Middle Income ◽

Middle Income Countries ◽

Surgical Services ◽

Improve Access ◽

Low And Middle Income

Download Full-text

Interventions to improve access to cataract surgical services and their impact on equity in low- and middle-income countries

Cochrane Database of Systematic Reviews ◽

10.1002/14651858.cd011307 ◽

2014 ◽

Cited By ~ 5

Author(s):

Jacqueline Ramke ◽

Vivian Welch ◽

Ilse Blignault ◽

Clare Gilbert ◽

Jennifer Petkovic ◽

...

Keyword(s):

Middle Income ◽

Middle Income Countries ◽

Surgical Services ◽

Improve Access ◽

Low And Middle Income

Download Full-text

Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries

International Journal of Health Policy and Management ◽

10.15171/ijhpm.2019.43 ◽

2019 ◽

Vol 8 (9) ◽

pp. 521-537

Author(s):

Katherine R. Iverson ◽

Emma Svensson ◽

Kristin Sonderman ◽

Ernest J. Barthélemy ◽

Isabelle Citron ◽

...

Keyword(s):

Surgical Procedures ◽

Surgical Care ◽

Optimal Distribution ◽

Case Volume ◽

Middle Income ◽

Middle Income Countries ◽

Surgical Services ◽

Surgical Workforce ◽

Improved Outcomes ◽

Low And Middle Income

Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.

Download Full-text